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News Gram™ August 2004

August 2004 ~ Volume 11, No. 1

Conflicts about the efficacy of psychotherapy are emerging in the workers' compensation arena. Stress claims are commonly among the most expensive cases employers face. Insurance companies, aware of the need to contain costs and lower premiums, want to know what therapies are most effective in returning patients to their jobs. Unfortunately, the process of psychotherapy doesn't lend itself readily to measurement and experimental testing as other therapeutic modalities in medicine. The result is a broad, vague area of indeterminate findings that do little to resolve the problem.

It's important to understand the kinds of treatment offered by different practitioners in psychiatry and psychology. Here are some guidelines in the broad field of psychiatric treatment that are helpful in evaluating treatment:

Pharmacological vs. psychological treatment - Psychiatrists these days lean heavily in the direction of medications as the primary means of alleviating emotional problems. Anti-depressants especially are employed to effect rapid return to normal functioning. These medications often have undesirable side effects that may discourage a patient from continuing to take them. However, the SSRI's -- Prozac, Paxil, Celexa and others -- have far fewer undesirable properties, which increases patient compliance.

These medicines are not perfect, however. Most patients, especially ones who come through the workers' compensation system, have specific complaints related to work that they think caused their depression. They want to understand what happened to make them feel so bad. Medications don't help them achieve such enlightenment. Such individuals will likely prefer psychotherapy. The problem is that psychotherapy is apt to be a much longer process than the use of medications. Also, combined treatment, i.e., psychotherapy and medication has a higher success rate than one or the other modality.

The case is much the same with anxiety-related disorders, which include post-traumatic stress disorder. Anti-anxiety agents as well as anti-depressants are very effective in most cases. However, psychotherapy -- in this instance, cognitive-behavioral therapy -- is extremely helpful. Again, a combined treatment program is probably the best route for most people.

When it comes to anti-psychotic agents, there is less of an issue in the field of workers' compensation because people who require such medications are less likely to be employed in full-time jobs. There is a subset, however, who do manage to hold down positions for many years and they often require ongoing treatment. In such arrangements, the job is an important therapeutic component of the ongoing treatment of such individuals. They also require combined psychotherapeutic intervention and pharmacological agents in order to maximize their effectiveness at work and in their personal lives.

Psychoanalytic vs. behavioral modalities - Psychoanalytic models of psychotherapy rely on the individual to gain and use insight into his problems. Based on newly found knowledge about oneself, it is possible to bring about longstanding changes in personality functioning -- or so the theory goes. There is some research to support this and related claims but there are still serious concerns about the effectiveness of psychotherapy, its associated cost and the length of time necessary to bring about substantial improvement in the patient. Insurance companies have been hesitant to pay for such treatment when the scientific basis for it is not entirely established.

Increasingly, insurers are requiring that therapists document their patients' progress. They want objective evidence that the money they are spending is bringing about the necessary improvement. The problem, though, is that insight-oriented psychotherapy does not always proceed in a straight-line manner. In some cases, the patient actually regresses for a while and then reorganizes his emotional resources. He may appear to have gotten worse when in fact he is preparing to make substantial progress. Explaining that to an insurance company may be a difficult business.

Behavioral modes of treatment, for the most part, do not rely on psychological insight. Instead, they are designed to change the specific behaviors that cause the individual to experience emotional distress. A person who becomes frantic on the freeway may undergo behavior therapy in order to alleviate the anxiety that prevents him from driving long distances. Someone who is frightened of elevators may be helped through a series of "desensitization" sessions. This form of treatment often is accomplished in a briefer time period. It also does not claim to achieve deep insight into the self. But it can be clear-headed and help get a patient back to work without the use of psychiatric medications, i.e., it can be cost-effective.

Evaluating a therapy - Here are three pointers in determining if a case is proceeding well or headed south:

1) Ask what the patient's view of his condition is. If the patient believes he is doing better, he probably is.

2) Ask what the objective signs of the patient's condition are present. The therapist should be able to list visible behaviors that are documented in his record. Such signs as facial expression, speech, posture, emotional expression and many others are the sorts of things to listen for. Mere subjective reporting is inadequate. Anyway, you've already asked for that in your first question.

3) Ask for the prognosis. If the therapist says the patient should be sufficiently improved to return to work in six weeks, then tells you the same thing a month later, you (and the patient) have lost one month.

Stress claims require careful scrutiny and sensitive handling. They can test your patience and frustrate you to the max. However, if you have a systematic way of knowing what kind of treatment you are dealing with, what questions to ask and how much information you need, you can help get claimants back to work in the shortest possible time. Keep in mind that work is usually beneficial to a person. It adds to his self-esteem, his sense of accomplishment, his connection to those around him and his bank account. For these reasons, assisting a worker in returning to his job isn't just good for the employer; it is part of his overall treatment program.

Conflicts about the efficacy of psychotherapy are emerging in the workers' compensation arena. Stress claims are commonly among the most expensive cases employers face. Insurance companies, aware of the need to contain costs and lower premiums, want to know what therapies are most effective in returning patients to their jobs. Unfortunately, the process of psychotherapy doesn't lend itself readily to measurement and experimental testing as other therapeutic modalities in medicine. The result is a broad, vague area of indeterminate findings that do little to resolve the problem.

It's important to understand the kinds of treatment offered by different practitioners in psychiatry and psychology. Here are some guidelines in the broad field of psychiatric treatment that are helpful in evaluating treatment:

Pharmacological vs. psychological treatment - Psychiatrists these days lean heavily in the direction of medications as the primary means of alleviating emotional problems. Anti-depressants especially are employed to effect rapid return to normal functioning. These medications often have undesirable side effects that may discourage a patient from continuing to take them. However, the SSRI's -- Prozac, Paxil, Celexa and others -- have far fewer undesirable properties, which increases patient compliance.

These medicines are not perfect, however. Most patients, especially ones who come through the workers' compensation system, have specific complaints related to work that they think caused their depression. They want to understand what happened to make them feel so bad. Medications don't help them achieve such enlightenment. Such individuals will likely prefer psychotherapy. The problem is that psychotherapy is apt to be a much longer process than the use of medications. Also, combined treatment, i.e., psychotherapy and medication has a higher success rate than one or the other modality.

The case is much the same with anxiety-related disorders, which include post-traumatic stress disorder. Anti-anxiety agents as well as anti-depressants are very effective in most cases. However, psychotherapy -- in this instance, cognitive-behavioral therapy -- is extremely helpful. Again, a combined treatment program is probably the best route for most people.

When it comes to anti-psychotic agents, there is less of an issue in the field of workers' compensation because people who require such medications are less likely to be employed in full-time jobs. There is a subset, however, who do manage to hold down positions for many years and they often require ongoing treatment. In such arrangements, the job is an important therapeutic component of the ongoing treatment of such individuals. They also require combined psychotherapeutic intervention and pharmacological agents in order to maximize their effectiveness at work and in their personal lives.

Psychoanalytic vs. behavioral modalities - Psychoanalytic models of psychotherapy rely on the individual to gain and use insight into his problems. Based on newly found knowledge about oneself, it is possible to bring about longstanding changes in personality functioning -- or so the theory goes. There is some research to support this and related claims but there are still serious concerns about the effectiveness of psychotherapy, its associated cost and the length of time necessary to bring about substantial improvement in the patient. Insurance companies have been hesitant to pay for such treatment when the scientific basis for it is not entirely established.

Increasingly, insurers are requiring that therapists document their patients' progress. They want objective evidence that the money they are spending is bringing about the necessary improvement. The problem, though, is that insight-oriented psychotherapy does not always proceed in a straight-line manner. In some cases, the patient actually regresses for a while and then reorganizes his emotional resources. He may appear to have gotten worse when in fact he is preparing to make substantial progress. Explaining that to an insurance company may be a difficult business.

Behavioral modes of treatment, for the most part, do not rely on psychological insight. Instead, they are designed to change the specific behaviors that cause the individual to experience emotional distress. A person who becomes frantic on the freeway may undergo behavior therapy in order to alleviate the anxiety that prevents him from driving long distances. Someone who is frightened of elevators may be helped through a series of "desensitization" sessions. This form of treatment often is accomplished in a briefer time period. It also does not claim to achieve deep insight into the self. But it can be clear-headed and help get a patient back to work without the use of psychiatric medications, i.e., it can be cost-effective.

Evaluating a therapy - Here are three pointers in determining if a case is proceeding well or headed south:

1) Ask what the patient's view of his condition is. If the patient believes he is doing better, he probably is.

2) Ask what the objective signs of the patient's condition are present. The therapist should be able to list visible behaviors that are documented in his record. Such signs as facial expression, speech, posture, emotional expression and many others are the sorts of things to listen for. Mere subjective reporting is inadequate. Anyway, you've already asked for that in your first question.

3) Ask for the prognosis. If the therapist says the patient should be sufficiently improved to return to work in six weeks, then tells you the same thing a month later, you (and the patient) have lost one month.

Stress claims require careful scrutiny and sensitive handling. They can test your patience and frustrate you to the max. However, if you have a systematic way of knowing what kind of treatment you are dealing with, what questions to ask and how much information you need, you can help get claimants back to work in the shortest possible time. Keep in mind that work is usually beneficial to a person. It adds to his self-esteem, his sense of accomplishment, his connection to those around him and his bank account. For these reasons, assisting a worker in returning to his job isn't just good for the employer; it is part of his overall treatment program.

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